Interesting perspective by ASA president, Dr. Lema

[toughlife]

I don't see how, for example, 7 MD's doing 1 on 1 anesthesia makes equal $ or greater $ than 1 MD supervising(billed as "unsupervised") 7 CRNA/AA's who have signed over 50% of their billing. IMO taking in 50% of 7 cases beats 1/7th of a pie. Multiply this scenerio by having MD partners at other facilities supervising in the same billing manner the same number of CRNA/AA's. This quickly adds up. As far as fraud and battery I am not sure where you live but the key in our practice arrangement is to bill all cases as "unsupervised" to get outside of TEFRA requirements. There is no need to bill " medically supervised" when you are already getting 50% of the CRNA/AA's billing anyway. I see what you are saying if the MD is salaried or a hosp. employee about making the same whether he/she supervises or does cases.

The hiring and supervising of CRNAs should be allowed only in academic centers for them to survive financially and allow residents time off for lectures and other academic activities. In the private world, this should be abolished to avoid the greed factor that many seem to make priority #1.

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[bestiller]

The hiring and supervising of CRNAs should be allowed only in academic centers for them to survive financially and allow residents time off for lectures and other academic activities. In the private world, this should be abolished to avoid the greed factor that many seem to make priority #1.

Excellent point! The problem though is that the "Medical Establishment" hung anesthesia out to dry long ago, and handed it over to nurses(they didn't take it) when it could have become "MD only administered" like any other specialty. The reality is whether it be an AA or CRNA someone other than an MD will always be able to perform the specailty of anesthesia(no other medical speciality has this delivery of care mode). This was brought on by the following reasons IMO, cost effectiveness of the mid-level provider(or perception of) and the historically poor work ethic(or perception of) of the anesthesiologist, more often than not mostly maligned by other Medical specialites. I doubt that if the AMA wanted "MD only" anesthesia providers they couldn't make that happen, with the political power and clout that they carry. The reality is they don't care who does anesthesia just as long as there is a provider.

 

[toughlife]

Excellent point! The problem though is that the "Medical Establishment" hung anesthesia out to dry long ago, and handed it over to nurses(they didn't take it) when it could have become "MD only administered" like any other specialty. The reality is whether it be an AA or CRNA someone other than an MD will always be able to perform the specailty of anesthesia(no other medical speciality has this delivery of care mode). This was brought on by the following reasons IMO, cost effectiveness of the mid-level provider(or perception of) and the historically poor work ethic(or perception of) of the anesthesiologist, more often than not mostly maligned by other Medical specialites. I doubt that if the AMA wanted "MD only" anesthesia providers they couldn't make that happen, with the political power and clout that they carry. The reality is they don't care who does anesthesia just as long as there is a provider.

I think the invasion of midlevels affects not only anesthesia but other especialties as well.

If the midlevel can bill the same as the physician then the cost-effectiveness is only a reason used by hospitals either to offset costs or increase their bottom line.

I agree with the poor work ethic of the anesthesiologists and see it now with some of my colleagues. Sad but true. As MilMD said it, we need to trim the fat that's weighing us down.

The way to get the AMA to back the specialty is to infiltrate it at the highest levels and that is being done as shown by the appointments of ASA members to the AMA board of trustees. Not sure whether it will work but they are trying.

 

[EtherMD]

Excellent point! The problem though is that the "Medical Establishment" hung anesthesia out to dry long ago, and handed it over to nurses(they didn't take it) when it could have become "MD only administered" like any other specialty. The reality is whether it be an AA or CRNA someone other than an MD will always be able to perform the specailty of anesthesia(no other medical speciality has this delivery of care mode). This was brought on by the following reasons IMO, cost effectiveness of the mid-level provider(or perception of) and the historically poor work ethic(or perception of) of the anesthesiologist, more often than not mostly maligned by other Medical specialites. I doubt that if the AMA wanted "MD only" anesthesia providers they couldn't make that happen, with the political power and clout that they carry. The reality is they don't care who does anesthesia just as long as there is a provider.

Too late for MDA only Anesthesia. CRNA's have a significant market share and are obtaining more each year. Your best chance at keeping your job is convincing the Academic Chairs to discontinue their CRNA programs immediately. Instead, they start AA Programs ASAP. This sends a clear message to the AANA that we are not interested in training our competition; we are interested in training our assistants. The AANA has no desire to assist you; on the contrary, they want to replace you and will do so by 2020 unless the leadership of the ASA and the GREEDY Academic chairs wise up and wise up soon.

 

[NewGuyBob]

I agree 100% with EtherMDs remarks!
Please, guys, at this point we all have to forget about MDA only anesthesiology! That idea divides the front and weakens our position. It is a beatuiful dream but reality is CRNAS are an integral part of the system. There is NOTHING we can do about it.
Even if AAAA try to gain privileges to practice independently, it would take them 50 - 60 years of lobbying before they get to where the AANA stands TODAY! I get from Dr. Lema's lecture that CRNA independent practice is imminent. They almost got it under Clinton's administration!

Ether: I am a resident at UB, and I can at least tell you that our program already reduced the # of positions. Right now there are 12 residents per year, starting 2007 there are only 8 positions for the match, the goal being 8 residents per year. I don't know if this is related to this issue but nevertheless I think is progress.

To be honest with you I don't have the balls to tell the administration to stop training CRNAs and start an AA program, but there must be something we can do. Collect signatures from every resident in America, with a petition I don't know...what other ideas do you have?

 

[johankriek]

Too late for MDA only Anesthesia. .

what are you talking about? where I am 3 hospitals.. there are no crnas... you go down to san diego and there are only crnas at UCSD that I know of.. In the wholecity of san diego.. there are physicians who WONT work with CRNAs...

 

[Gern Blansten]

Ether,

I am sure you mean well. I am not sure who you are or why you have suddenly caught fire on this issue. You may have a point about the academic programs being at fault for "training the competition." Your argument loses credibility when you admit that you are giving these newly graduated CRNAs real life training that they did not get in school. Training that will allow them to make it tougher fornew grads to find a job. It seems to me that you are quick to point the finger at everyone else as the source of the problem when you have been reaping the benefits in your pocketbook for who knows how many years. I am happy that you are excited about the issue and hoping to get something done about it. I find it somewhat funny that you blame everyone except yourself and others like you for the problem.

It sort of reminds me of the newly converted Christian who finds religion and is suddenly better than everyone else and condemns those who disagree with him.

I must say that you bring up many strong and valid points that I agree with. I just wish that you could do it without all of the hypocritical rhetoric.

This is just constructive criticism. I hope you keep up the good work.

 

[EtherMD]

Ether,

I am sure you mean well. I am not sure who you are or why you have suddenly caught fire on this issue. You may have a point about the academic programs being at fault for "training the competition." Your argument loses credibility when you admit that you are giving these newly graduated CRNAs real life training that they did not get in school. Training that will allow them to make it tougher fornew grads to find a job. It seems to me that you are quick to point the finger at everyone else as the source of the problem when you have been reaping the benefits in your pocketbook for who knows how many years. I am happy that you are excited about the issue and hoping to get something done about it. I find it somewhat funny that you blame everyone except yourself and others like you for the problem.

It sort of reminds me of the newly converted Christian who finds religion and is suddenly better than everyone else and condemns those who disagree with him.

I must say that you bring up many strong and valid points that I agree with. I just wish that you could do it without all of the hypocritical rhetoric.

This is just constructive criticism. I hope you keep up the good work.

What I meant by all SOLO MDA anesthesia was CRNA's are a significant percentage of the work force. We can not go to a 100% solo MDA model if we wanted to. It would take a 50% increase in new graduates and decades to get there. CRNA's are here to stay and we need to deal with them.

I employ CRNA's but do not teach students. I teach newly graduated CRNA's the skills necessary for my hospital. I could never find enough MD Anesthesia providers to fill all the spots and CRNA's are still about 40-50% less per hour.
This is not hypocritical of me as I believe in the Mid-Level Provider concept under the supervision of an MDA. The AA fits my belief to a tee but there are only a few hundred of them. So, we hire the provider that is available to us.

Now, if the academic programs gave us a choice the AA's would fine plenty of jobs. However, many academic programs TRAIN student Nurse Anesthetists INSTEAD of AA's. People like me then hire these CRNA's to work for them. Am I "innocent" completely of the problem, No. But, am I the major component of causing the situation we are in? No. The academic programs COULD choose to stop training SRNA's and train AA's. This would give me a CHOICE in the market place where none exists now. Then , you could call me a "hypocrite." Until this occurs I need to staff the operating rooms appropriately or the AMC will! I guarantee the local AMC does not care about these issues one bit.

Would I consider an all MDA model at my hospital instead of CRNA's? Yes. The problem is my hospital would lose tens of millions of dollars converting to an MD only model. Even if they agreed to this new model the hospital subsidy would need to increase and locums Anesthesiologists would be needed in large numbers until all the positions were filled. In the mean time there would be disruption of services at the hospital. My gut feeling is the hospital would go with an AMC and/or a totally new department if this much chaos occurs.

People like you need to realize the anesthesia care team model is not going away. This model is a major portion of the work force in the USA. Hence, the academic programs need to provide an alternative mid-level anesthetist who works under the MDA: the AA. This is the solution to the AANA and the CRNA independent practice issue. In order for MDA's like myself to hire AA's the academic programs must train them and soon.

 

[Darwin]

what are you talking about? where I am 3 hospitals.. there are no crnas... you go down to san diego and there are only crnas at UCSD that I know of.. In the wholecity of san diego.. there are physicians who WONT work with CRNAs...

Only CRNA's at UCSD? UCSD is an academic anesthesiology department, and one that is fairly renowned. Ever heard of Benumof, Wilson, etc? I'm not quite sure what you mean by this....

 

[Darwin]

Just got the understanding of your wording...as if to say, the only place in San Diego that utilizes CRNA's is UCSD. My apologies.

 

[dhb]

can someone explain the differences between CRNA and AA, scope of practice etc..?

 

[EtherMD]

can someone explain the differences between CRNA and AA, scope of practice etc..?

Why not go to www.allnurses.com and ask them. They will be more than happy to explain it in detail. AA's must work under the supervision of an Anesthesiologist at all times. In most states the law limits the ratio to 4:1.
CRNA's have more latitude in their independence. 14 States require no medical supervision and the rest just require a Physician (surgeon or dentist) of some sort to medically supervise them. There is no legal requirement to limit to the ratio so an MDA could supervise 7:1 and bill as medical supervision or CRNA only depending on the situation. However, most Groups do use a 4:1 ratio for CRNA's as well because this qualifies as medical direction and Medicare prefers this ratio for 100% reimbursement.

AA's can do everything a CRNA can except bill independently for their services. AA's are not licensed in all states (only 16 states at this time) so that is another major difference as well. Go to www.anesthesiaassistant.com for the list of states.

 

[jwk]

can someone explain the differences between CRNA and AA, scope of practice etc..?

Ether pretty much got it. AA's are masters-level anesthesia providers trained in a medical school environment. We are 100% anesthesia care team committed - no independent practice is sought, and in fact is not allowed by legislation. EVERY AA works with an anesthesiologist - we cannot work independently for a podiatrist, dentist, plastic surgeon, etc. as CRNA's can.

AA's are recognized anesthesia providers by CMS and private insurors along with MD's and CRNA's. With the exception of independent practice, our scope of practice is the same as CRNA's.

The professional organization for AA's is the American Academy of Anesthesiologist Assistants (AAAA). Our official website is www.anesthetist.org (accept no imitations).

 

[EtherMD]

Ether pretty much got it. AA's are masters-level anesthesia providers trained in a medical school environment. We are 100% anesthesia care team committed - no independent practice is sought, and in fact is not allowed by legislation. EVERY AA works with an anesthesiologist - we cannot work independently for a podiatrist, dentist, plastic surgeon, etc. as CRNA's can.

AA's are recognized anesthesia providers by CMS and private insurors along with MD's and CRNA's. With the exception of independent practice, our scope of practice is the same as CRNA's.

The professional organization for AA's is the American Academy of Anesthesiologist Assistants (AAAA). Our official website is www.anesthetist.org (accept no imitations).

If it was up to me (which it's not) or I was Dr. Lema the first thing on my agenda would be 10-20 new AA programs. I would lobby hard to close Academic CRNA programs and open AA programs. There is nothing the AANA could do to stop this move. In addition, I would open AA programs in North Carolina and double the ASA's effort in getting licensure for AA's.

The lethargic ASA needs to wake up and realize that training one's competitor is very poor business sense when one could train a true assistant.
The AA represents this true assistant in the operating room. Most College students/graduates could take the additional classes to enter AA school.
Once they realize the potential salary for an AA they will come in droves.

To continue with the status quo of training CRNA's to replace MDA's is stupid at best. Train someone whose main goal is NOT to replace you in the future.
Sometimes I wonder if scarecrow is in charge of our leadership.

 

[toughlife]

If it was up to me (which it's not) or I was Dr. Lema the first thing on my agenda would be 10-20 new AA programs. I would lobby hard to close Academic CRNA programs and open AA programs. There is nothing the AANA could do to stop this move. In addition, I would open AA programs in North Carolina and double the ASA's effort in getting licensure for AA's.

The lethargic ASA needs to wake up and realize that training one's competitor is very poor business sense when one could train a true assistant.
The AA represents this true assistant in the operating room. Most College students/graduates could take the additional classes to enter AA school.
Once they realize the potential salary for an AA they will come in droves.

To continue with the status quo of training CRNA's to replace MDA's is stupid at best. Train someone whose main goal is NOT to replace you in the future.
Sometimes I wonder if scarecrow is in charge of our leadership.

Problem with the leadership is that they are mainly older anesthesiologists who are already set for life, have no concerns about income and do not want to rock the boat since they will be long retired by the time the **** hits the fan. So what is their incentive for change?


I want an early 40s kinda guy running the show who has a lot to lose if the CRNAs get their way running the show.

 

[SleepIsGood]

Another thing with this whole "perioperative physician" push. Realize that CCM is the LOWEST paying with the worst reimbursments. This is the reason that many many anesthesiologists have avoided that specialty like the plague and have gone to the OR. When I told an attending about my feelings about possibly pursuing a CCM fellowship, his first words were something like, "you do realize you would be taking a huge pay cut".

Unless reimbursements for CCM related matters goes up, what is the incentive for a financially burdened resident/attending to enter perioperative medicine (which is an off shoot of CCM)? Furthermore, just a heads up. Hospitalists (ie medicine docs) are competing for these same positions. Hospitalists will likely be content with the lower reimbursements since it's better than what their norm is.

True it's not all about pay, but let's face it reimbursement is an issue.

 

[johankriek]

Another thing with this whole "perioperative physician" push. Realize that CCM is the LOWEST paying with the worst reimbursments. This is the reason that many many anesthesiologists have avoided that specialty like the plague and have gone to the OR. When I told an attending about my feelings about possibly pursuing a CCM fellowship, his first words were something like, "you do realize you would be taking a huge pay cut".

Unless reimbursements for CCM related matters goes up, what is the incentive for a financially burdened resident/attending to enter perioperative medicine (which is an off shoot of CCM)? Furthermore, just a heads up. Hospitalists (ie medicine docs) are competing for these same positions. Hospitalists will likely be content with the lower reimbursements since it's better than what their norm is.

True it's not all about pay, but let's face it reimbursement is an issue.

have you all been to an ICU. It is a very difficult place to work. And im not talking clinical decision making (which is the easy part). I spent quite a bit of time in the ICU as an intern. 9 months total in some way shape or form and the required 3 months in anesthesia residency. there's a year right there. you can go weeks wondering if you are helping anybody. But I DO like the topics in critical care. It is emotionally charged and draining.. There are issues constantly. We are clearly in the best position to take care of critically ill patients.

 

[johankriek]

Problem with the leadership is that they are mainly older anesthesiologists who are already set for life, have no concerns about income and do not want to rock the boat since they will be long retired by the time the **** hits the fan. So what is their incentive for change?


I want an early 40s kinda guy running the show who has a lot to lose if the CRNAs get their way running the show.

you hit the nail on the head tough. These guys dont care. and Im afraid if WE dont insist they start working for our dues it will be more of the same. And i say this because I know the guy who will be asa president in a few years.. HE is like 4th or 5th down the line now in the asa. and each year they keepp moving up til they become president. and the guy is a total mush. He is afraid of going against the grain at all. we brought issues to his attention many times and he did nothing about it.. He is a smart guy but he is not gonna do anything for the organization when he becomes president. He is just gonna put that on his resume and thats it..

 

[Be a Pro]

you hit the nail on the head tough. These guys dont care. and Im afraid if WE dont insist they start working for our dues it will be more of the same. And i say this because I know the guy who will be asa president in a few years.. HE is like 4th or 5th down the line now in the asa. and each year they keepp moving up til they become president. and the guy is a total mush. He is afraid of going against the grain at all. we brought issues to his attention many times and he did nothing about it.. He is a smart guy but he is not gonna do anything for the organization when he becomes president. He is just gonna put that on his resume and thats it..

I seriously hope that this is not true, and these guys have limited time to demonstrate that it is not. I think, however, that soon the public absence of an ASA message would seem so peculiar to ASA members (at least those with many years of practice still ahead of them) that there would be no way for the ASA -- even were it driven by a pushover -- to avoid public posturing, e.g. ad campaign etc...

 

[toughlife]

you hit the nail on the head tough. These guys dont care. and Im afraid if WE dont insist they start working for our dues it will be more of the same. And i say this because I know the guy who will be asa president in a few years.. HE is like 4th or 5th down the line now in the asa. and each year they keepp moving up til they become president. and the guy is a total mush. He is afraid of going against the grain at all. we brought issues to his attention many times and he did nothing about it.. He is a smart guy but he is not gonna do anything for the organization when he becomes president. He is just gonna put that on his resume and thats it..

This is the reason why I am against waiting for the ASA to do everything for us. They need to be in tune and act upon their constituency's wishes. If they don't do as the majority wants, then they need to be pushed aside and action needs to be taken individually at the state level. I am sure that for many, being in the ASA committee is just a resume builder. I wish individuals with that mentality stayed away from those leadership positions and deferred them to those who really want to make a difference.

 

[SleepIsGood]

I think that it's great that we are all very resolute in this matter. I know in times past in this forum this issue has been brought up and it's been battered away from all the nay sayers. I think now, more than ever though we have seen PROOF of what the CRNAs are capable of. This issue is frustrating to all of us that are physicians having gone through so much training.

I've just finished approving many of the requests of ASA attendings/residents who had applied for membership to the Private Forum on here (so guys that have please go to the top of the main Gas Forums website and you will see "anesthesiology club" ).

There are a few ppl on here that are trying to collaborate on a good document to put together as a public campaign. Once it's complete I think we should have a show of numbers on the PRIVATE forum of who is willing to put their name,etc behind this document. Then in UNISON we present it to the ASA offficials and see what they say. Depending on what type of answer we get, we should make our move--hopefully in unison with the ASA.

I think the major reason that ASA leaders are not outspoken on this issue is because they do not know how much backing from us they would have. If we can show them that there is a great interest within the ASA to make a public campaign, change will occur. The leaders will feel confident with fighting for us.

Remember guys, this is something that effects us 'younger' docs. As someone pointed above, many (definitely not all) physicians in private practice save a great deal of $$ utilizing CRNAs/AAs. It's true many of these guys are making >500k and dont really care about change. But at what cost? Perhaps at the expense of our future job market.

We need to show our more senior colleagues and the public the value and quality provided by an anesthesiologist. Working together is what we as anesthesiology attendings/residents should do to demonstrate that we are a united front on this matter. Otherwise the nurses,et al will try to prey of of our division.